What nursing action is indicated when a child receiving a unit of packed red blood cells complains of chills, headache, and nausea?
a. Continue the infusion and take the child's vital signs.
b. Stop the infusion immediately and notify the physician.
c. Slow the infusion and assess for cessation of symptoms.
d. Start a dextrose solution and stay with the child.
B
If a reaction is suspected, as in this case, the transfusion is stopped immediately and the physician is notified. If the child is displaying signs of a transfusion reaction, the transfusion cannot continue. Dextrose solutions are never infused with blood products because the dextrose causes hemolysis. This action does not address the blood infusion.
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An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:
a. Long bones tend to shorten with age. b. The vertebral column shortens. c. A significant loss of subcutaneous fat occurs. d. A thickening of the intervertebral disks develops.
A nurse working with a patient in individual crisis intervention would characterize the approaches used as:
a. open-ended. b. passive and indirect. c. active, focused, and explorative. d. psychoanalytic-based techniques.
When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state:
a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. You'll lose more weight." c. "Let's discuss the relationship between exercise and weight loss and how that affects your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."
Handwashing should be performed for a minimum of
A. 5 to 10 seconds. B. 10 to 15 seconds. C. 15 to 20 seconds. D. 20 to 30 seconds.